Acupuncture in manual therapy 9 the hip

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9 The hip Jennie Longbottom CHAPTER CONTENTS Introduction 151 Soft tissue injuries 151 Femoral syndromes 152 Hip syndromes 152 Osteoarthrosis 153 Acupuncture intervention 154 References 165 Introduction The hip joint is a multiaxial ball-and-socket, synovial joint that connects the head of the femur and the pelvic acetabulum The head of the femur forms approximately two-thirds of a sphere and is covered with hyaline cartilage (Nicholls 2004) Twenty-two muscles cross the hip in order to stabilize the joint and move the femur during locomotion It is has evolved to operate under loads exceeding three times the weight of the body, and is controlled by muscles of enormous power and extraordinary accurate coordination (Strange 1965) Any excess or unstable load may damage both soft tissue and joint structures, depending on the position of the joint at the time (Sims 1999) Many problems of the hip complex show movement dysfunctions of the joint, in combination with the lumbar spine, sacroiliac joint, neurodynamic structures, © 2010 Elsevier Ltd DOI: 10.1016/B978-0-443-06782-2.00009-8 and muscular systems (Hengeveld & Banks 2005), all of which need accurate assessment before appropriate and effective interventions are chosen Soft tissue injuries The hip is an integral component in load transference during upper and lower limb performance, with approximately 30% of hip pain in young adults remaining without clear diagnosis Controversial diagnoses such as acetabular tear, femoro-acetabular impingement syndrome, instability, and osteoarthrosis (OA) are referred to (Nicholls 2004) In sport, the hip joint has been attributed to contributing between 0.5 and 14% of athletic injuries (Reid 1988; van Mechelen et al 1992) and adductor muscle-related groin pain is a common presentation in the athlete Hölmich (2007) reviewed 207 cases of groin pain in the sporting population; 18% of all cases occurred in runners From a clinical standpoint, sports-related groin pain can be classified into four clinical subgroups (Hölmich 2007): l l l l Adductor-related groin pain; Abdominal-related groin pain; Pubic symphysis stress reaction; and Hip-related groin pain High-velocity eccentric muscle contractions may injure muscles and tendons, or damage may be done by oblique, explosive forces with sudden movement bursts (Sharma & Maffulli 2005) The potential for certain muscles to be injured is greater for some The hip CHapter Table 9.1  Muscle activity in running phases Phase of running Muscle activity Plane of activity % muscle activity Motion required Swing Iliopsoas Saggital plane quadriceps iliopsoas hamstrings 84% concentric and eccentric muscle activity Hip flexion increases with speed End of swing Gluteus maximus Transverse plane external hip rotators 6.4% of concentric and eccentric muscle activity Decelerates hip flexion and internal rotation; increases with speed Start of stance Gluteus maximus Transverse plane external hip rotators 6.4% of concentric and eccentric muscle activity Extension of hip Late swing to early middle stance Gluteus medius Frontal Plane Provides adductor stability; prevents adduction of hip prior to and after foot contact Tensor fascia lata Gluteus medius tibialis anterior 18.9% of concentric and eccentric muscle activity More active with sprinting Adapted from Sahramann (2001) than others, multijoint muscles being at greater risk because of their potential stretch over two joints An accurate diagnosis and an assessment of the presenting muscle strain will rely on: l l l l l The nature of the presenting injury; Gait analysis; Palpation; Muscle stretching; and The elimination of differential pathologies or the inclusion of current pathologies The goals of therapeutic intervention are to assist new muscle fibre growth and muscle fibre alignment, and reduce adhesion formation (Niemuth 2007) Numerous studies have documented the role of the hip muscles during running using electromyography (EMG) analysis to describe muscle activity in the swing and stance phases of running (Knuesel et al 2005; Sahraman 2001) (Table 9.1) A common source of pain in runners is iliotibial band syndrome (ITBS), which is caused by repetitive friction of the iliotibial band sliding across the lateral femoral condyle Fredericson et al (2000) hypothesized that weakness of the gluteus medius muscle causes overfiring and tightness of the tensor fascia lata (TFL) and ITBS, resulting in significant weakness of the hip abductors of the injured leg in injured runners In the acute stages of injury, gentle concentric strengthening activity is preferred, and as recovery is achieved, eccentric strengthening is particularly 152 effective in promoting new collagen, reversing chronic degenerative tendon changes (LaStayo et al 2003), and promoting increased circulation for enhanced tenocyte and myocyte activity (Khan 1999) Rehabilitation of proprioception is essential to avoid re-injury and return the patient to full function, especially the athlete Repeated movements and sustained postures alter tissues that control the characteristics of movement, causing movement impairment (Sahramann 2001) Two main categories of movement impairment syndromes have been described: femoral and hip syndromes Femoral syndromes These are believed to be impairments of accessory motions, which cause irritation of tissues Femoral syndromes occur because of either excessive accessory motion or when accessory motion is occurring when it should not Hip syndromes These are impairments of physiological motions that produce pain in muscles associated with the movement Detailed examination in order to identify and rectify movement impairment syndromes reveals a number of positive findings necessary for accurate confirmation of the diagnosis A diagnosis of Jennie Longbottom movement impairment using a variety of tests will identify the movement direction that must be corrected; these include: l l l l l l l Hip alignment; Movement patterns; Muscle length; Muscle strength; Muscle stiffness; Pattern of muscle recruitment; and Presence of joint susceptibility to movement in a specific direction (Sahramann 2001) The growth in the number of individuals participating in organized sport has contributed to an increase in the prevalence of hip-related injuries Rehabilitation of the injured athlete requires knowledge of the physical and psychological demands on the patient, made by the sport and his or her expectation (Konin & Nofsinger 2007) Capsular and ligamentous injuries are not as commonly seen as musculotendinous injuries, but may arise from trauma and overuse, requiring arthroscopic diagnosis (Baber et al 1999) Amongst the acute problems encountered are: Acetabular labrum tears (Fitzgerald 1995; Ikeda et al 1988; McCarthy et al 2003); Acetabular rim syndrome (Ito et al 2001; Klaue et al 1991; Reynolds et al 2007); Instability and sprained ligamentum teres (Bellabarba et al 2007); and Loose bodies (Villar 1992) l l l l Stress fractures develop as a result of the weakening and subsequent failure of the bone With regard to the hip, individuals who progressively increase the duration of repetitive impact loading to the lower limb are most at risk to injury (Kahan et al 1994) Korpelainen et al (2001) found that those who were at highest risk were individuals with high longitudinal arches; leg length inequalities; excessive forefoot varus; and menstrual irregularities Diagnosis involves careful examination of all capsular movement patterns Currently trial periods of non-weight-bearing for up to months are advocated for patients with acute intra-articular dysfunction (Fitzgerald 1995; Ikeda et al 1988) In the acute stage the aim is to reduce weight bearing, relieve pain and inflammation, maintain range of movement, and maintain aerobic fitness Overactivity in any of the hip muscles would increase compression forces on the joint Both TFL and ITB overactivity demonstrate increased stress distributions in the ch a p t e r cartilage of the superior part of the joint, which may lead to degeneration (Kummer 1993) The piriformis and obturator externus muscles may provide forces capable of producing posterior joint wear, whilst iliopsoas and rectus femoris muscles which have direct connections with the anterior capsule of the hip may demonstrate anterior joint wear (Sims 1999) Muscle weakness or shortening as a result of an active trigger point (TrPt) in the gluteus medius may affect the hip abductor vector, causing a Trendelenberg gait, whilst fatigue may bring about a change in the muscular synergies, leading to adverse handling of repetitive impact loads (Mizrahi et al 1997) Therefore it is important to identify any musculoskeletal dysfunction and modulate pain in order to facilitate rehabilitation, and prevent further abnormal forces contributing to the more extensive pain of OA or joint changes later in life Osteoarthrosis Osteoarthrosis is the most common reason for total hip and total knee replacement among adults aged over 30 years, and symptomatic hip OA occurs in approximately 3% of the UK population (Felson & Zhang 1998) Mechanical factors are of importance in the aetiology of OA; there is increasing evidence that an abnormal labrum is implicated in the early onset of OA (Ferguson et al 2003) In a normal hip, the capsule has no limiting effect other than at the end range positions; however, it has been argued that a person with capsular restriction, in attempting to walk normally, increases hip joint loads by stretching the tight capsule (Crowninshield et al 1978) Therefore, the hip is subjected to dynamic loads on impact as well as dynamic forces of equilibrium in single-leg stance; alterations in one component may affect another There has been limited research into the effectiveness of physiotherapy for OA hip, but in recent years, there have been an increasing number of randomized controlled trials (RCTs) evaluating the effect of exercise therapy (Hoeksma et al 2004; Tak et al 2005; van Baar et al 1998), manual therapy (Hoeksma et al 2004), acupuncture (Stener-Victorin et al 2004), and self-management (Heuts et al 2005) The effects of long-term exercise have yet to be demonstrated (Tak et al 2005; van Baar et al 1998) Hoeksma et al (2004) focused on specific manipulations and mobilization of the joint, as well 153 CHapter The hip as exercise therapy involving active exercises to improve muscle function and joint motion The treatment period was weeks (nine sessions) The primary outcome was general perceived improvement (GPI) after treatment; secondary outcomes included reduced pain, and increased hip function, walking speed, range of movement (ROM), and quality of life No major differences were found in baseline characteristics between the study groups, with 81% improvement in the manual therapy group and 50% in the exercise group Patients in the manual therapy group had significantly better outcomes on pain, stiffness, hip function, and ROM, indicating that the effects of manual therapy, endured after 29 weeks, and that it was superior to the exercise therapy programme in patients with OA of the hip Manual therapy techniques such as joint mobilizations, stretching, and joint traction/ distraction appear to offer improvements in quality of life, function, and walking tolerance The European League against Rheumatism (EULAR) and the UK-based, multidisciplinary MOVE consensus group have developed recommendations for the management of OA hip based on the best available scientific evidence (Roddy et al 2004; Zhang et al 2005) The consensus is that strengthening, aerobic, and proprioceptive exercises are recommended, but the recommendations identify the need to increase research into the most effective exercise programme for OA hip with reference to compliance, effectiveness on land versus water, and individual versus group exercise (Roddy et al 2004; Zhang et al 2005) In a survey of current practice for the management of OA hip in Republic of Ireland, French (2007) found limited evidence for a number of physiotherapy interventions, recommending that the role of education and self-management should be investigated further Despite manual therapy being virtually unresearched, it was used by 96% of respondents in this survey Puett and Griffin (1994) reviewed 15 controlled trials on non-medicinal and non-invasive therapies for hip and knee OA, and concluded that exercises reduced pain and improved function, but the optimal exercise regime has not been determined Active and passive ROM has been considered an important part of rehabilitation for patients with OA as a means of regaining joint mobility and function (Biloxi 1998; Prentice 1992) Deyle et al (2000) evaluated the effectiveness of manual therapy and exercise therapy in OA knee The treatment involved 154 eight clinical visits, which produced a 52% improvement in function, stiffness, and pain, as measured by the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and a 12% improvement in walk test scores Falconer et al (1992) found improvements in motion (11%), pain (33%), and gait speed (11%) over 4–6 weeks after 12 sessions of exercise combined with manual therapy for patients with clinically diagnosed OA knee A combination of manual therapy and supervised exercise appears to be more effective than no formal intervention on improving walking distance, and alleviating pain, dysfunction, and stiffness in patients with OA, helping to defer or decrease the need for surgical intervention Proprioceptive deficits contribute to functional instability, which could ultimately lead to further microtrauma and re-injury (Lephart et al 1997) Thus, incorporating a proprioceptive element into a physical therapy programme is suggested for joint disorders Sensorimotor training to promote proprioceptive acuity and muscle contraction for patients with lower limb OA has been advocated since 1990 particularly for the re-education of the proprioceptors (Sharma et al 1997; Vad et al 2002) A therapeutic exercise programme incorporating sensory input to facilitate dynamic joint stabilization may retrain altered afferent pathways to enhance the proprioception of joint movement and improve a patient’s function However, until now, there has been no standard training protocol available Closedchain exercise has been shown to give a better result with respect to facilitating proprioceptors than open-chain exercise (Beard et al 1994; Fitzgerald 1997) The exercises should be performed in various positions throughout the full ROM since the different afferent responses have been observed in different joint positions (Lephart et al 1997) Acupuncture intervention Treatment for OA is largely symptomatic, including analgesics, non- steroidal anti-inflammatory drugs (NSAIDs), glucosamine, topical analgesics such as capsaicin cream, and exercise, behavioural interventions, and surgical treatment (Felson et al 2000) No drug treatment is without risks and adverse effects; thus, non-pharmacological interventions are attractive Kwon et al (2006) conducted a systematic review and meta-analysis of acupuncture for peripheral joint Jennie Longbottom OA, suggesting on the basis of best-evidence synthesis that the data evidence for manual acupuncture could be classified as fairly strong Manual acupuncture appeared to reduce pain compared to waiting list controls and sham acupuncture, thus suggesting analgesic effects beyond a placebo response Electroacupuncture (EA) was found to be superior to NSAID on the visual analogue scale (VAS) and WOMAC outcomes Stener-Victorin et al (2004) evaluated 45 patients, aged between 42 and 86 years who had radiographic changes consistent with OA of the hip Those with pain related to motion load and ache were selected The subjects were randomly allocated to EA, hydrotherapy, both in combination with patient education, or patient education alone The outcome measures were the Disability Rating Index, the Global Self Rating, and the VAS Assessments were taken before the intervention and immediately after the last treatment, and later, at 1, 3, and months Electroacupuncture and hydrotherapy, both in combination with patient education, induce long-lasting effects, as shown by reduced pain and ache, and by increased functional activity and quality of life, as demonstrated by differences in pre- and post-treatment assessments Pain related to motion and pain on load was reduced up to months after the last treatment in the hydrotherapy group and up to months in the EA group Ache during the day was significantly improved in both the EA and hydrotherapy groups up to months after the last treatment Ache during the night was reduced in the hydrotherapy and EA groups up to and months after the last treatment, respectively Disability in functional activities was improved in the EA and hydrotherapy groups up to months after the last treatment Quality of life was also improved in EA and hydrotherapy groups up to months after the last treatment There were no changes in the education group alone In conclusion, EA and hydrotherapy, both in combination with patient education, induce long-lasting effects, reduced pain and increased functional activity and quality of life, as demonstrated by differences in the pre- and post-treatment assessments The principle aims of acupuncture are to modulate pain and inflammation; improve circulation to the hip joint; and maintain muscle length and strength Initially treatment should be aimed at segmental (Table 9.2) inhibition and pain-gate mechanisms whilst aiding blood flow and stimulating an anti-inflammatory response Local segmental points ch a p t e r on the Bladder channel will facilitate segmental dorsal horn inhibition, whilst distal points corresponding to the dermatome involvement (Fig 9.1) will encourage a descending inhibitory response Here a choice of points may be available, depending on the pain pattern With the enormous muscle bulk running over the hip joint, the myofascial element should not be ignored Resolution of associated trigger points will often reduce pain and facilitate muscle imbalance re-education; pain and abnormal function may often be attributed to myofascial trigger points (MTrPts) If the patient presents with both myofascial and articular dysfunction rehabilitation is generally steady and progressive (Whyte-Ferguson & Gerwin 2005) Myofascial involvement commonly involves the following muscles: l l l l l l l l Quadratus lumborum; Gluteus minimus; Tensor fascia lata; Piriformis; Abdominal oblique; Iliopsoas; Pectineus; and Semimembrinosis The exact aetiology and pathophysiology of MTrPts remain unknown The MTrPts have been described as having a characteristic EMG pattern termed spontaneous electrical activity (SEA) (Chen et al 2001) This SEA is characterized by continuous low-level EMG activity with superimposed largeamplitude spikes (Simmons et al 1995) Some EMG studies have recorded SEA active MTrPts in both humans (Hubbard & Berkoff 1993) and rabbits (Chen et al 2001) Contemporary opinion is that SEA is the result of acetylcholine leakage from the motor end-plate The magnitude of this leakage is at a sufficient level to create a mini depolarization of the postsynaptic junction and result in the contraction of a small number of muscle fibres rather that the whole muscle (Huguenin et al 2005) Continued acetylcholine release and subsequent muscle contraction are thought to reduce the oxygen supply to the muscle, and consequently, an ischaemic environment ensues in which there is insufficient adenosine triphosphate (ATP) available to initiate release of the actin-myosin complex Chen et al (2001) found that the SEA in rabbit MTrPts could be reduced with needling In comparison to controlled needling, needling of the active 155 CHapter The hip Table 9.2  Segmental innervation and acupuncture points Segmental innervation Segmental acupuncture points Dermatome points Anterior hip joint capsule is innervated by sensory articular branches from the femoral nerve L2 L3 BL23 BL24 HJJ @ L2/L3 GV4 @ L2 ST30  ST31 GB31 ST34 SP12 LIV11 Anteromedial innervation is determined by the articular branches of the obturator nerve LIV11 LIV10 SP11 SP10 SP11 SP10 Posterior hip joint and capsule The sciatic nerve BL25 BL26 GB30 GV3 HJJ@ L5/S1 Posteromedial section of the hip joint capsule is innervated by articular branches of the anterior rectus femoral nerve BL25 BL26 BL53 BL54 Posterolateral section of the hip joint capsule innervated by superior gluteal nerve BL26 BL27 KID10 BL36 BL37 S1-S3 sciatic nerve BL27 BL28 BL29 BL36 BL37 BL40 BL60 BL62 Notes: BL, Bladder; HJJ, Huatuojiaji; GV, Governor Vessel; ST, Stomach; LIV, Liver; SP, Spleen; KID, Kidney TrPt in the rabbit resulted in significantly lower normalized SEA in out of rabbits Although this study primarily provides evidence for the efficacy of MTrPt needling in reducing SEA, it remains unknown whether reducing SEA is required to achieve pain relief The study by Chen et al (2001) did not measure pressure-pain threshold pre- or post-treatment To date, there is insufficient evidence to support or refute a reduction in SEA in MTrPt acupuncture In addition to a peripheral effect on the motor end-plate, MTrPt injection has been shown to activate diffuse noxious inhibitory control (DNIC) Fine et al (1988) investigated the effects of administering the opioid antagonist naloxone in MTrPt injections The study found that MTrPt injections were effective in improving ROM and pressurepain scores The administration of 10 mg naloxone 156 significantly reversed the effects of the MTrPt injections The findings of this study would suggest that central opioid activation is an underlying mechanism in the pain relief obtained from MTrPt injections Activation of DNIC and the subsequent release of opioids has been shown to reduce nociceptive transmission to higher centres at the spinal cord level (Fine et al 1988) It is possible that the reason why some studies fail to demonstrate a difference between placebo and MTrPt is that the placebo needling is of sufficient level of stimulus to activate DNIC Furthermore, the clinical improvement from manual, soft tissue MTrPt therapy may also share the same pathway for its analgesic effects with acupuncture Clinically, it is relevant to consider what level of stimulus is effective in activating DNIC and achieving pain relief in subjects with MTrPt, rather ch a p t e r Jennie Longbottom C2 Subcostal, T12 Femoral branch of genitofemoral L1,2 Ilioinguinal L1 Lateral femoral cutaneous of thigh L2,3 Obturator L2,3,4 Med and int femoral cutaneous of thigh L2,3 Infrapatellar branch of saphenous Lateral cutaneous of calf and leg L5, S1,2 Saphenous L3,4 C3 C4 T1 C5 T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 L1 L2 T12 L3 L4 L5 T1 C6 C8 C7 S5 S4 S3 S2 S1 Superficial peroneal L4,5 S1 Sural S1,2 Deep peroneal (medial terminal branch) Figure 9.1 l Segmental and dermatome innervation than debating whether the stimulus is a placebo or a real treatment (Smith & Crowther 2002) The sympathetic nervous system (SNS) has also been implicated in MTrPts In an animal model Chen et al (1998) demonstrated that phentolomine reduced the SEA in rabbit MTrPts when compared with a control injection of saline Although direct extrapolation of this finding to human subjects is limited, the study provides some preliminary data that suggest that sympathetic activity may contribute to myofascial MTrPt pain Clinically, it was hypothesized that the increased physiological demand on the muscle created an energy crisis where insufficient ATP was present to initiate skeletal muscle relaxation ATP is required for two processes of skeletal muscle relaxation The first requirement for ATP is to decouple the myosin head from the actin molecule Secondly, ATP is required to actively pump Ca2 from the cytoplasm into the sarcoplasmic retinaculum A reduction in active transport of Ca2 by the calcium pump results in reduced Ca2 concentrations in the sarcoplasmic reticulum Reduced levels of sarcoplasmic Ca2 have been suggested to prevent the actin and myosin attachment (Schwellnus et al 1997) Bengtsson et al (1986) found reduced levels of high-energy phosphate bonds and increased levels of low-energy phosphate bonds in the MTrPt sites compared to non-tender muscle locations Although these findings go some way to supporting the energy crisis theory, the above authors failed to show that any differences were demonstrated by product levels of anaerobic metabolism As an alternative to the energy crisis hypothesis, changes in spinal reflex and supraspinal control of 157 CHapter The hip the alpha motor nerve may be responsible for the development of the adductor muscle hypertonicity observed in athletes Spinal control of the alpha motor nerve is essential for muscle relaxation (Schwellnus 1997) Under normal physiological conditions, excitatory input from the motor cortex, extrapyramidal, and muscle spindles must be decreased before muscle relaxation can occur (Gong 1993) Experimental evidence from animal studies show that, under fatigued conditions, type 1a muscle spindle afferent firing increases and type 1b Golgi tendon afferent firing decreases (Nelson & Hutton 1985) It would appear that muscle fatigue at the spinal level increases alpha motor activity as a result of the combination of increased type 1a and reduced type 1b afferent activity The evidence is inconclusive as to whether MTrPt needling is effective In a systematic review and meta-analysis of RCTs, Tough et al (2009) found limited evidence that deep needling directly into MTrPts has an overall treatment effect when compared with standardized care Whilst the result of the meta-analysis of TrPt needling, when compared with placebo controls, does not attain statistical significance, the overall direction could be compatible with a treatment effect of dry needling on MTrPt pain However, the limited sample size and poor quality of the seven studies included highlights and supports the need for larger scale, good quality, and placebo-controlled RCTs in this field The use of acupuncture, whether using MTrPt or traditional Chinese acupuncture points, as means of reducing pain, and as precursors to manual and exercise therapy, appears to offer some enhancement of successful rehabilitation programmes for the management of pain in OA, although the research evidence is sparse and larger, placebo-controlled, pragmatic RCTs are required Case Study Anonymous Introduction A 20-year-old male decathlete presented to a sports medicine department complaining of a 3-week history of left-sided adductor groin pain The subject recalled that while attending a training camp, he had developed pain in his left groin following javelin practice During this training session, the athlete was instructed by his coach to increase his approach speed and increase the height of his leg crossover The subject could not recall any acute injury during the training session; however, approximately 30 minutes after the session he developed mild pain and tightness in the left groin The athlete had competed the previous weekend in the 400-m, pole vault and discus without any impact on his performance; however, he felt decidedly apprehensive about competing in further hurdles and high jump training because of the risk of re-injury The main symptom that the subject reported was intermittent sharp left groin pain, rated as 60/100 on the VAS, when he was turning over in bed, coughing, or attempting to jump (see Fig 9.2) His functional limitations were an inability to undertake high jump, javelin, and hurdle training at a level of less than 65% of the required intensity level His goals were to resume full training; and compete in the national under-23 decathlon championships in weeks The following investigations involving an ultrasound scan were performed; no muscle injury was detected, with no evidence of posterior abdominal wall disruption or positive cough impulse The clinical presentation suggested that the athlete had presented with myofascial adductor-compartmentrelated groin pain Although this implied an adductor muscle injury, the lack of a clear mechanism of injury during the training session and the negative ultrasound scan findings negated this hypothesis The following treatment plan was discussed: l Deactivate active MTrPts; l Strengthen the adductor muscle; l Improve hip mechanics in both the passive and active ranges; and l Manage training intensity to minimize continued adductor hypertonicity Pa I/T sharp/ tightness 6/10 Figure 9.2 l Body chart showing location of symptoms (Continued) 158 Jennie Longbottom ch a p t e r Case Study (Continued) The clinical presentation of the subject backed the diagnosis of adductor-related groin pain The main clinical findings supporting the hypothesis of adductor compartment pain were discomfort on resisted contraction and palpation of the adductor compartment The main negative clinical test that would further support the diagnosis of adductor-related groin pain were the negative Pubic Symphysis Stress Test; normal hip examination; symmetry; non-provocative neurodynamic tests; and the negative lumbar spine and sacroiliac joint pain provocation tests (Table 9.3) The clinical history and ultrasound scan results did not support the clinical findings of an adductor muscle injury The majority of these injuries occur with an eccentric hip abduction combined with hip external rotation, and most athletes are able to recall the exact moment of injury (Brukner & Khan 2007) Considering the aforementioned factors, an alternate explanation for the subject’s symptoms had to be considered The clinical presentation was more in keeping with active MTrPts in adductor longus and magnus muscles The requirement of the athlete to increase the speed of his approach run in the coronal plane, coupled with a loss of hip extension, would necessitate an increase in adductor muscle recruitment to achieve the desired movement pattern MTrPt needling was not used during the first three treatment sessions Initially, post isometric inhibitory soft tissue techniques with digital ischaemic pressure were used to treat the adductor muscle MTrPt Although these techniques resulted in an immediate reduction in pain during the adductor squeeze test, there was no carryover into the next treatment session, with the subject reporting only a short-term improvement following therapy Based on the clinical presentation, it was decided to include MTrPt needling into the management of this adductor-related groin pain Needling was selected to deactivate the active MTrPt in the adductor muscles, which reproduced the subject’s symptoms This athlete was seen on six occasions The first three treatment sessions comprised local soft-tissue techniques to the adductor muscles and implementation of a rehabilitation programme Although the subject demonstrated an immediate improvement in isometric hip adduction strength, as measured by the pressure Table 9.3  Assessment Observation Lordotic posture Increased tone lumbar erector spinae Reduced gluteal bulk and tone Functional assessment Overhead squat reduced hip flexion range Lateral lunge left reproduced pain Single leg squat left increased knee adduction Neural provocation testing Femoral and obturator nerve tests L  R No abnormal mechanosensitivity detected Active range of motion Reduced lumbar extension 80%R2 No pain reproduction Reduced hip extension on left in comparison to right Muscle length tests Rectus femoris, iliotibial band restricted on right Adductor longus limited on left because of muscle guarding Palpation Hypertonicity of adductor compartment with active trigger points reproducing pain adductor longus and adductor magnus No abdominal wall or pubic symphysis tenderness Special tests ve  ve  ve  ve  ve  ve  Pubic Symphysis Stress test SIJ pain provocation and active SLR hip impingement and acetabular labrum testing adductor squeeze test 60°  P1 180 mmHg adductor squeeze at 0° P1  40 mmHg eccentric sit-up with rotational variations (Continued) 159 CHapter The hip Case Study (Continued) Table 9.4  Acupuncture Selection Treatment Location Outcome Adductor magnus Reduced pain on groin pressure cuff testing 220 mmHg Adductor longus Adductor longus Pressure cuff score 280 mmHg before pain onset Adductor magnus Adductor magnus, two locations Adductor longus Bicep femoris Groin pressure cuff scores  300 mmHg cuff, this progress was not carried over into subsequent treatment sessions Moreover, adductor muscle hypertonicity was still evident in comparison to the subject’s other side and he still reported a restricted ability to undertake his hurdle and jumping sessions Following the first session of acupuncture, his painfree adduction power improved to 220 mmHg More importantly, this progress was carried over into following treatments (Table 9.4) Following two further sessions the subject was pain-free on muscle testing and his strength had returned to the level measured on pre-season testing He reported that he was in full training at 100% intensity Clinical examination revealed that there was no adductor muscle hypertonicity in comparison to the contralateral muscle group Discussion To date, only one study has investigated the use of MTrPt needling in the elite sports population (Huguenin et al 2005) This report investigated placebo and needling of gluteal MTrPt in athletes with posterior thigh pain Both needling techniques resulted in subjective improvements in the levels of gluteal and hamstring tightness during running Objectively, the straight leg raise test and internal hip rotation range remained unchanged The findings of the above study would suggest that both active and placebo needling techniques might have a central neural mechanism underpinning their effect Huguenin et al suggested that this might be as a result of activation of descending noxious inhibitory control Delta fibre stimulation could explain why the MTrPt needling was more effective than soft-tissue techniques in reducing the present subject’s groin pain Delta fibre stimulation has been shown to produce the most effective stimulus for segmental inhibition of pain (Bars & Willer 2002) Potentially, MTrPt needling could have resulted in a larger number of A-delta (A) fibres being stimulated than those in soft-tissue techniques; this would result in a more intense noxious stimulus to the central nervous system Bars and Willer found that the intensity of the peripheral stimulus would appear to be more important than the mode of stimulus delivery in the activation of DNIC mechanisms Case Study Sharon Helsby Introduction A 55-year-old woman presented with an 8-week history of right lateral hip pain The subject could not recall any trauma associated with the onset of her symptoms, but reported that the pain had gradually been getting worse After weeks of having symptoms, which showed no signs of resolving, she saw her general practitioner who prescribed NSAIDs, which helped to settle the pain slightly, and sent the subject for a hip X-ray The X-ray confirmed a diagnosis of right hip moderate OA and she was referred to an orthopaedic consultant The diagnosis was confirmed and the subject was given the option of a hydrocortisone injection for temporary relief, a Birmingham hip resurfacing operation, or conservative treatment, which comprised of NSAIDs and physiotherapy She was not keen on having surgery and opted for the conservative approach, so she was referred to physiotherapy Subjective assessment On initial presentation the subject reported an intermittent deep ache in the lateral aspect of her right hip; she described the ache as 60/100 on VAS The symptoms were at their worst first thing in the morning, on rising, at which time she also felt stiffness The pain and stiffness settled as she started walking and were completely gone following her morning shower The subject’s symptoms were aggravated throughout the day by activities such as getting into and out of a car and walking for periods more than 15 minutes (Continued) 160 Jennie Longbottom ch a p t e r Case Study (Continued) Table 9.5  Acupuncture treatment protocol Treatment Local points Distal points Outcome measures piriformis MTrPtR LI4B Decreased tenderness on palpation of piriformis VAS 50/100 Right internal rotation 15° Right abduction ISQ GB29R GB30R GB43R LI4B VAS 40/100 Right internal rotation 15° Right abduction 35° GB29R GB30R GB43R LI4 B VAS 30/100 Right internal rotation 15° Right abduction 35° GB29R GB30R GB43R LI4B GB34B VAS 30/100 Right internal rotation 20° Right abduction 40° GB29R GB30R GB43R LI4B GB34B VAS 20/100 Right internal rotation 20° Right abduction 40° Notes: B, bilateral; R, right She was currently able to continue her job as a secretary since this did not aggravate her symptoms However, the subject had stopped going to the gym, which she usually attended twice a week, because she found that the symptoms were increased immediately following the session, especially when she used the treadmill Objective assessment On observation, the subject had a normal gait pattern with some mild gluteus maximus wasting on the right Hip active range of movement on the right was limited by pain and stiffness into internal rotation (5°) and abduction (30°); all other hip movements were full and pain free Passive ROM equalled that of the active limitation, with a bony end-feel on abduction and a springy end-feel on internal rotation Both abduction and internal rotation reproduced the subject’s symptoms Muscle power was reduced to 4/5 on the Oxford Scale on abduction, and internal rotation and extension Specifically, the right gluteus maximus and medius muscles were weak on muscle testing to 4/5 Furthermore, palpation revealed local tenderness and muscle spasm provocation over the piriformis muscle on the right side Treatment regime Physiotherapy treatment began with advice and education about the subject’s condition, including self-help strategies and adaptions to lifestyle The subject was also given a home exercise programme of stretching and strengthening exercises in order to help stabilize the hip joint There had been no change in VAS or ROM at this point and therefore, the first acupuncture session concentrated upon deactivation of active MTrPt in piriformis muscle (Table 9.5), which was restricting internal rotation and produced a positive pain referral pattern on palpation Clinical reasoning Acupuncture was chosen as the treatment modality primarily for its analgesic properties in the treatment of pain (Tiquia 1996) During acupuncture, peripheral terminals of nociceptors in the skin are stimulated, which in turn release vasodilative substances such as calcitonin gene-related neuropeptide and histamine, leading to vasodilation and increased blood flow to the local area (Sato et al 2000) A further reason for choosing acupuncture, as a treatment modality is that there are many available research studies that form a reliable evidence base supporting its use as a pain-relieving modality for a variety of musculoskeletal disorders Furthermore, a few studies specifically support the effectiveness of acupuncture for OA of the hip (Haslam 2001); many more support its effectiveness on OA of the knee (Barlas 2005; Berman et al 2004; Linde et al 2005; Sherman & Cherkin 2005; Tillu et al 2001) (Continued) 161 CHapter The hip Case Study (Continued) Initially, MTrPt acupuncture into the piriformis muscle bulk was performed at the location of the MTrPt, as described by Cummings (2000) Meridian acupuncture along the Gall Bladder channel was chosen for local use, with variable distal points The Gall Bladder meridian is said to have an influence on muscles and tendons, the courses of which pass over the lateral and posterior aspects of the hip (Haslam 2001) Large Intestine (LI4) was chosen as a distal point because of its general pain-relieving influence (Ellis 1994) Bilateral needling was carried out for the distal points since this method has been shown to be more effective than a unilateral approach because of the resulting bilateral stimulation of the ascending and descending spinal pathways involved in pain modulation (Tillu et al 2001) Manual stimulation was carried out twice throughout each session to maintain de Qi Outcome Following the first session, the subject responded with a decrease in local tenderness in the right piriformis muscle, a 10/100 (VAS) reduction in local pain on the VAS and a 10° improvement in internal rotation with no change to her abduction Following the next five sessions, all outcome measures improved By the sixth session her VAS score had improved from her original rating of 60/100 to 20/100 The subject’s active ROM had also improved significantly on internal rotation, which was originally 5°, but improved to 20° by the sixth session Her range of abduction had also improved from 30° to 40° By the last session the subject had also reported improvements to her functional ability and reported less intense stiffness in the mornings, which also resolved more quickly than before treatment She also reported to be able to walk for periods longer than 30 minutes before pain came on, instead of the original 15 minutes Other symptoms, such as getting into and out of her car, had also settled post-treatment Furthermore, the subject had returned to the gym on a twice-weekly basis, but concentrated on non-weight-bearing activities with no problems Discussion Positive results were gained from the acupuncture protocol employed, in terms of both the subject’s VAS scale and her active ROM However, only a total of six sessions were carried out Meng et al (2003) highlighted 10 sessions of acupuncture as being effective as a standard frequency of treatments, although this study was carried out on chronic low back pain patients Therefore, further improvements to VAS and active ROM may have continued had more sessions been employed The chosen acupuncture protocol used points on the gall bladder meridian for local application Although this brought about benefits to the VAS and active ROM, other meridians or local points could have been considered Haslam (2001) used Ah Shi points around the greater trochanter in a north, south, east, and west formation and produced good results Haslam (2001) also used Stomach 44, which is not only a distal point, but also one that Ellis (1994) reported as having a strong pain-relieving influence Another point that could have been considered was Bladder 23 because this offers a segmental approach to anterior hip pain The positive outcome from combining acupuncture and manual therapy in the present case study not only aided in pain modulation, but also facilitated further rehabilitation and a consequent return to function and exercise Case study James Thomson Introduction This presentation seeks to develop a rationale for the use of acupuncture in a case study involving the treatment of a runner presenting with symptoms consistent with piriformis origin The physiology and reasoning behind the use of acupuncture is explored, along with a record of the progress of treatment, discussion of the different means by which acupuncture facilitated the development of diagnosis and broadened the outlook of the physiotherapist with regards to both the uses of acupuncture and the importance of treatment which is not necessarily confined to a medical mode of thinking Acupuncture has evolved in Western medical practice from its original roots in traditional Chinese 162 medicine (TCM) to become one of the most pervasive elements of the management of neuromusculoskeletal pain in the primary healthcare setting (Kam et al 2002) Whilst it may remain the subject of some controversy, the clinical benefits have been studied across a variety of contexts, including shoulder pain (Gunn & Milbrandt 1977; Tukmachi 1999); back pain (Ernst & White 1998); temporomandibular joint dysfunction (Aung 1996); and osteoarthritis of the knee (Berman et al 2004) Acupuncture has not been without its critics and unfortunately research has predominantly examined acupuncture in patient groups assumed to be homogenous, despite the fact that patients presenting to physiotherapy departments are far removed from this (Continued) ch a p t e r Jennie Longbottom Case Study (Continued) factor The use of clinical reasoning models and more appropriate treatment rationales may ensure that an evidence base develops, which is not only specific to the postulated effects of acupuncture, but which has direct influences on our reasoning (Bradnam 2002, 2003) The present case study discusses the rationale for the use of acupuncture in the management and diagnosis of a combination of piriformis TrPt combined with mechanical lumbar and pelvic pain in a runner The treatment performed could not be considered consistent with a strictly scientific rationale, but was successful partly because the training of the therapist had included the implicit guidance that a key part of the use of acupuncture included following clinical hypotheses and pursuing possible sources of TrPt dysfunction in the area As such, acupuncture proved a key method in confirming these hypotheses Subjective assessment The subject was a 40-year-old female working as a secretary in local government; a sedentary occupation She had been a successful club athlete, retiring at the time of the birth of her first child, but had since taken up running again and had completed a number of fun runs over the past few years, together with running most evenings Whilst running one month before her appointment, she experienced a sharp stabbing pain down the back of her right thigh, followed by pins and needles, which settled within minutes She continued with her running schedule, occasionally experiencing the same symptoms, for weeks At this time she began to feel a constant ‘niggly’ ache in her right buttock, after a few hours of sitting at work This ache became worse and at the time of presentation (one month on) was a 60/100 on the VAS The pain was centred in her buttock, radiating to her posterior thigh and was aggravated by sitting and running Her general practitioner had diagnosed a lumbar facet joint irritation and administered ‘keep moving’ advice and a course of NSAIDs with little effect Objective assessment The key objective markers are demonstrated in Table 9.6 The presentation was confusing as to whether presenting pain was emanating from a muscular origin with postural dysfunction in the lumbar spine, or a piriformis referral, approximating both an L5 and S1 facet joint irritation with a corresponding referral pattern The distal symptoms experienced whilst running could have been more consistent with either piriformis syndrome or a nerve root involvement The initial treatment plan was to initiate abdominal contractions through exercise, utilizing the core stability model involving the recruitment of transversus and multifidus A temporary abdominal brace was used until such time as the subject’s own core Table 9.6  Main objective markers Marker Interpretation 20° anterior pelvic tilt ASIS and Muscular dysfunction, issues PSIS angle with lumbar biomechanics Poor abdominal muscle tone As above Bilateral pronating forefoot position Increased work of hip lateral rotators in running SLR (L) clear Indicative of either nerve SLR (R) slight radiation in right root tension or piriformis posterior thigh trigger points Lumbar ROM pain free No real help to diagnosis Hip ROM full Combined hip flexion and adduction reproduced pain pattern Activation of trigger points? Palpation of taut band of piriformis muscle Muscle twitch Reproduction of pain pattern Needle grasp Pain propagation stability was sufficiently strong enough and the spine had achieved a good neutral position, to resume running (Tsao & Hodges 2002) Clinical reasoning for acupuncture Treatment was compounded with some clinical doubt as to whether the subject’s symptoms were lumbar, pelvic, ergonomic, biomechanical, or related to TrPts Using Bradnam’s (2003) clinical reasoning model, acupuncture was used to aid diagnosis, relieve pain, and serve as a potential precursor to muscle imbalance exercises An increasing understanding of the pathophysiology of pain, particularly with regards to how it is initiated and why it persists, is now leading to more selective use of acupuncture in its treatment (Bradnam 2003) and to address the following pain mechanisms: l Stimulation of nociceptive pathways, release of histamines, and stimulation of nerve endings (Wu et al 1999); l Activation of anti-nociceptive pathways in the hypothalamus (Sato et al 1986); and l Pre- and post-synaptic inhibition through production of endogenous opioids, histamines, endorphins, serotonin and dopamine, beta-endorphins, and cortisol (Longbottom 2008) More specific to the present case study is the use of acupuncture in pain relief through the stimulation of TrPts (Continued) 163 CHapter The hip Case Study (Continued) It is interesting to note that a close correlation has been explored between TrPts points and acupuncture points, despite their derivation in such different philosophies (Melzack et al 1977) The deeper pistoning method used within TrPt needling has been postulated as resultant from stimulation of underlying pathological processes, linked by Melzack (1977) to nodules of fibrous tissue With the presentation of biomechanical abnormalities, e.g bilateral pronating foot position and anteriorly tilted pelvis, combined with the repetitive running, had possibly caused either an acute strain or more likely a repetitive strain insult to the piriformis muscle, consistent with the findings of Andersen et al (1995), that repetitive movements in a fixed, or slightly awkward posture were often sufficient to initiate myofascial pain Within the pathophysiological approach, the formation of TrPts is thought to be a result of one of two initial processes l Overuse or disuse injury results in dysfunction in the motor endplate, leading to continuous release of small amounts of acetylcholine into the synaptic cleft and permanent depolarisation of the muscle (Hubbard & Berkoff 1993) l It has also been suggested that damage to the sarcoplasmic reticulum causes the same continuous muscle contraction through increased calcium deposition (from Hecker et al 2008) The result of both these processes is the continuous contraction of actin and myosin filaments, the production of contractile, painful knots in the muscle, and compression of the blood supply, leading to the classic ‘energy crisis’ as described by Travell and Simons (1992) This repeating process leads to nociceptive pain and increased sympathetic activity TrPt needling is thought to alter significantly the motor end-plate, resulting in a stretch in the dysfunctional muscle fibres that will ultimately lead to realignment of muscle fibres (Langevin 2001) In terms of specific research, there appears to be a lack of well-controlled randomized controlled trials to advocate use (Cummings & White 2001) However, this review did advocate the use of dry needling as an adjunct to treatment, although no significant benefit over placebo was demonstrated Acupuncture point rationale and use Thomas (1997) considers several parameters important in initiating a positive clinical response to acupuncture intervention, these include: l Site of needle insertion; l Intensity of stimulation; l Duration of treatment; l Timing of intervention relative to tissue healing; and l Mode of stimulation Two TrPts were selected within the piriformis muscle after manual palpation revealed a contractile knot, Table 9.7  Rationale for use of acupuncture points Point Location Rationale TrPt Along the line of piriformis, close to insertion Needle grasp Referral of patient pain pattern TrPt Close to the muscle origin Needle grasp Referral of patient pain pattern BL54 Cun lateral to sacral hiatus Local acupuncture point GB30 Lateral side of hip, on line connecting the greater trochanter and sacral hiatus Local point for posterior hip pain taut band, and patient pain propagation (Hecker et al 2008) (Table 9.7) On needling in the first session, twitch response was not elicited (Hong 1994), but during sessions and a localized twitch was evident This is considered by Hong (1994) and in Travell and Simons (1992) as important both to confirm needle placement and as it appears to improve treatment outcome Also considered were acupuncture points Gall Bladder 34 (GB34) and GB39, which may have been used as a segmental approach to the lumbar pain presented by the subject; using a clinical reasoning model, with focus on the myofascial pain presentation, allowed the clinician to reassess to determine whether more extensive global pain relief was indeed necessary following this initial intervention In terms of intensity and duration, caution was used in the initial session, but once patient compliance was achieved, treatments were more robust in subsequent sessions, with improved outcomes The subject demonstrated improvement in the frequency and intensity of symptoms, although manual and exercise intervention, incorporating a phased running regime and ergonomic and muscle imbalance interventions to further assist in return to full function, is ongoing Outcomes Acupuncture and TrPt intervention was commenced at treatment 2, following the establishment of an advice and exercise regime (Table 9.8) Two TrPts were deactivated within piriformis, whilst GB30 was added in order to enhance the spinal, segmental inhibition of pain and possibly reduced treatment soreness The reported, subjective pain at this treatment was 60/100 VAS At treatments and 2, the same procedure was repeated As palpable tender knots and taut bands remained, deep (Continued) 164 Jennie Longbottom ch a p t e r Case Study (Continued) Table 9.8  Outcome measurements and results Session Points used Outcome (initial) Outcome (7 days) Nil-established exercise regime GB30 TrPts and Some pain exhibited during treatment Piriformis stretching exercise given VAS 60/100 GB30 TrPts and Deep, bruising sensation Lasted days piriformis stretches VAS 30/100 painful when running GB30 TrPts and Treatment soreness for one day VAS 0/100 at rest 30/100 on stretching piriformis piriformis muscle stretching exercises were added at this stage and VAS reduced to 30/100 At the final treatment 4, the TrPts were treated, the patient reported a VAS of 0/100 at rest, 30/100 when stretching At time of writing, the treatment was ongoing, with increased hip stretching and lower quadrant muscle imbalance work One of the key areas of improvement has been the ability of the subject to adhere to a good, effective stretching regime Her VAS improved significantly with three sessions, whilst further interventions, addressing the biomechanics and ergonomics will hopefully restore muscle imbalance and facilitate her return to normal function whilst minimizing the incidence of repeated trauma References Andersen, J.H., Kaergaard, A., Rasmussen, K., 1995 Myofascial Pain in different occupational groups with monotonous repetitive work Pain 3, 57 Aung, S.K., 1996 The treatment of temporomandibular joint dysfunction and distress: a Chinese traditional medical approach Am J Acupunct 24 (4), 255–267 Baber, Y., Robinson, A., Villar, R., 1999 Is diagnostic arthroscopy worthwhile? 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Study (Continued) The clinical presentation of the subject backed the diagnosis of adductor-related groin pain The main clinical findings supporting the hypothesis of adductor compartment pain were... complaining of a 3-week history of left-sided adductor groin pain The subject recalled that while attending a training camp, he had developed pain in his left groin following javelin practice During